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You are watching: The great and middle cardiac veins drain blood into the

StatPearls . Sweetheart Island (FL): StatPearls Publishing; 2021 Jan-.


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Introduction

The intricacy the the coronary venous system highlights both the complexity and also beauty that the human being heart"s anatomical features. As biomedical science and technology advance, coronary veins have gained far-ranging clinical prestige for treatment and intervention because that cardiac patient globally. Coronary veins are responsible for draining deoxygenated blood indigenous the myocardium into the cardiac chambers. Comprised of two venous systems, coronary veins classify right into either the greater cardiac venous device or the smaller sized cardiac venous system. The higher cardiac venous mechanism drains the bulk of the deoxygenated blood, when the smaller cardiac venous mechanism drains a smaller part of the deoxygenated blood to its corresponding heart chambers. Physiological variability the coronary veins likewise exists among a diverse patient population. Acquiring a substantial understanding of the anatomy that the coronary venous vasculature is thus vital to improve clinical expertise and assist informed physician decision-making because that future cardiovascular patients.  


Structure and also Function

The main physiological role of the coronary veins is to carry deoxygenated blood indigenous the myocardium and also empty them into the chambers of the heart. Coronary veins deserve to be organized into two groups: the greater and also smaller cardiac venous system.

Greater Cardiac Venous System

The higher cardiac venous system returns three-quarters the the deoxygenated blood indigenous the myocardium to the cardiac chambers. The main venous vasculature of this system has the coronary sinus and its tributaries, marginal veins, anterior cardiac veins, ventricular veins, and also atrial veins.<1><2>

     Coronary Sinus

The coronary sinus is the biggest cardiac vein with multiple smaller sized vessels converging right into it. Located along the left posterior atrioventricular groove, the coronary sinus empties straight into the ideal atrium through the coronary sinus orifice. The venous tributaries the merge right into the coronary sinus include the good cardiac vein, center cardiac vein, small cardiac vein, left posterior ventricular, and also oblique cardiac vein.<2><3>

     Great Cardiac Vein

Starting native the apex that the heart and running parallel v the anterior interventricular artery, the an excellent cardiac vein travels up along the anterior interventricular sulcus in the direction of the basic of the left atrium’s auricle<2>. When the vein get the left margin the the heart, it circumvents to the posterior side and eventually converges through the oblique vein of the left atrium right into the coronary sinus. The good cardiac vein empties the blood from both ventricles and the left atrium right into the ideal atrium.<3><4>

     Middle Cardiac Vein

The middle cardiac vein originates from the apex the the heart but on the posterior side. The middle cardiac vein travels alongside the posterior interventricular artery in the posterior interventricular sulcus, and empties deoxygenated blood right into the coronary sinus.<3>

     Small Cardiac Vein

Located in the coronary sulcus in between the best atrium and right ventricle, the tiny cardiac vein eventually coalesces with the coronary sinus ~ above the posterior side of the heart and drains to the right atrium.<3> The tiny cardiac vein additionally runs parallel to the appropriate marginal branch the the appropriate coronary artery top top the anterior surface of the heart and collects deoxygenated blood native the posterior side of the appropriate chambers.<5>

     Right Marginal Vein

The ideal marginal vein is situated on the an extremely inferior margin that the anterior surface ar of the heart and also serves to north the anterior and also diaphragmatic wall surfaces of the right ventricle.<3> This tiny vein is likewise known for merging v the small cardiac vein in the coronary sulcus.<5>

     Anterior Cardiac Veins

Anterior cardiac veins return blood native the anterior right ventricle and drain them straight into the anterior appropriate atrium. The anterior cardiac veins are an ext superior to the ideal marginal vein.<4>

     Left Marginal Vein

Also known as the obtuse marginal vein, the left marginal vein drains the myocardium that the left ventricle.<2> This vein travels along the left slope marginal surface of the heart.

     Left and Right Ventricular Veins

The left and also right ventricular veins vary from person to person, however generally, they role to drainpipe the exterior walls of the ventricles<6>.

     Left and also Right Atrial Veins

The left atrial veins consist of the septal veins, posterolateral veins, and posterosuperior veins that all lug the deoxygenated blood native the left atrium into the best atrium. The appropriate atrial veins drainpipe the appropriate atrial walls.<7>

     Inferior Vein that the Left Ventricle

Also recognized as the posterior vein the the left ventricle, the worse left ventricular vein return the deoxygenated blood from the inferior and also lateral walls of the left ventricle right into the coronary sinus. This vein travels between the middle and good cardiac veins.<5>

     Oblique Vein of the Left Atrium

The oblique vein the the left atrium is a reasonably small-sized vein the rounds obliquely and also inferiorly towards the posterior left atrium. The vein is likewise observed come unite through the an excellent cardiac vein to merge v the distal coronary sinus.<4>

Smaller Cardiac Venous System

The smaller cardiac venous device returns one-quarter that the deoxygenated blood native the within layers of the myocardium come the cardiac chambers. This system is largely composed of Thebesian veins draining deoxygenated blood from every sections of the myocardium chambers. Thebesian veins likewise drain the best side that the heart more than the left side.<8>


Embryology

During embryo development, the angiogenesis of coronary veins starts from the sinus venosus, an embryonic vein the returns blood to the heart<9> The venous endothelial cells from the sinus venosus move towards the surface of the myocardium and then differentiate into coronary veins and also their tributaries.


Blood Supply and also Lymphatics

Coronary veins obtain oxygenated blood and nourishment native coronary arteries and their tributaries. Additionally, large veins particularly receive nutrient-rich blood supply from the vasa vasorum, a network of microvessels. Vasa vasorum are likewise known together the ship of the vessels.<10>


Nerves

The heart and its venous vasculature interact in autonomic innervation. Located in the brainstem, the medulla plays a significant role in regulating the sympathetic and also parasympathetic nerves to the heart and also its blood vessels. In the sympathetic division, the sorry nerves leave the medulla and synapse through preganglionic yarn in the top thoracic spinal cord. The preganglionic fibers climate synapse with postganglionic fibers in the sorry ganglia, where the postganglionic nerves finally travel to and synapse v the target sites in the heart and also coronary veins.<11> In the parasympathetic division, the preganglionic efferent fibers of the vagus nerve exit the medulla and synapse v postganglionic fibers in ~ the vascular venous tissue.<12> Overall, sympathetic innervation reasons coronary veins to dilate, when parasympathetic innervation reasons coronary veins come constrict.


Muscles

Coronary veins are composed of three structural layers, however only the tunica media or the center layer that the coronary veins is smooth muscle. Comparatively, the tunica media is diluent in coronary veins 보다 in coronary arteries.<13>


Physiologic Variants

There are countless anatomical variations of the cardiac venous system from differed numbers the tributaries to diverse diameters and also locations the the cardiac veins. Clinically, understanding distinctive structural variations can prove salient for a patient’s diagnosis and cardiac intervention. The many notable venous variations involve the an excellent cardiac vein and coronary sinus.<2> The good cardiac vein usually travels along the anterior interventricular sulcus, but some patients’ an excellent cardiac veins course intramurally, which have the right to inhibit venous flow<5> Furthermore, other clinical findings have discovered patients through duplicate coronary sinuses, which might also influence the draining of the venous system.<14>


Surgical Considerations

As the biggest coronary vein, the coronary sinus is often utilized together an anatomical landmark for orientation throughout cardiothoracic surgery. Although many cardiac treatment procedures take place for adult patients, infant and pediatric patients suffering from congenital heart defects also undergo cardiac operations. One congenital atrial septal defect, recognized as the unroofed coronary sinus, entails an anomalous and also unclosed connection between the coronary sinus and also the left atrium.<15> If left untreated, unroofed coronary sinus have the right to lead to love disease. Closure in between the coronary sinus and also left atrium via a stent requires mindful surgical management and coordinated teamwork among physicians and medical employee to supply the finest medical treatment for patients and their families.


Clinical Significance

The coronary venous system encompasses far-reaching clinical worth for a wide variety of cardiac interventional procedures, including cardiac catheterization, retrograde cardioplegia, reperfusion that cardiac veins, medicine delivery, stem cell therapy, and also lead placement among many.

For clinical treatment and procedures, the most salient anatomical attribute of the cardiac veins is the coronary sinus and its venous tributaries. As soon as patients undergo open-heart surgeries or have obstructions in their coronary arteries, the myocardium must proceed to get nourishment. To prevent ischemia that the operated heart, implementing reperfusion of the coronary sinus and its venous tributaries permits an effective reverse flow of nourishment.<16> The distribution of drugs and cardioplegic remedies via the coronary sinus likewise holds clinical significance. In several study reports, cardiothoracic surgeons have actually observed that distribution through cardiac veins have the right to prolong call time and also enhance the efficacy the the therapy even an ext than the distribution through cardiac arteries can.<17><18>

Due to its optimal location and also high visibility, the coronary sinus is additionally a well-known vein because that retrograde cardioplegia, short-term cessation that the heart’s activity, and is targeted for left ventricular command placement.<19> because that cardiac catheterization and pacemaker placement, the left ventricular lead developments through the coronary sinus into the posterior or lateral coronary vein to go into the left ventricular wall. This procedure enables physicians to advice cardiac conduction and also the patient’s as whole coronary health.<20> native therapeutic drug shipment to permanent pacemaker insertion, these miscellaneous cardiac techniques highlight the prestige of the coronary venous system and also the expertise of its distinct anatomy.

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Other Issues

Electrocardiography, computed tomographic (CT) angiography, and also magnetic resonance imaging (MRI) are terrific noninvasive diagnostic devices to evaluate the coronary sinus and also detect potential cardiac anomalies, such as congenital abnormalities and vessel obstruction.<21>